“BEST” PRACTICES FOR SURFACE DISINFECTION AND NEW ROOM DECONTAMINATION METHODS

1. “BEST” PRACTICES FORSURFACE DISINFECTION AND NEW ROOM DECONTAMINATION METHODS William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill, USA

2. Disclosure This educational activity is brought to you, in part, by Advanced Sterilization Products (ASP) and Ethicon. The speaker receives an honorarium from ASP and Ethicon and must present information in compliance with FDA requirements applicable to ASP. This sponsored presentation is not intended to be used as training guide. Before using any medical device, review all relevant package inserts with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the devices (s). The third party trademarks used herein if any are trademarks of their respective owners.

3. LECTURE OBJECTIVES • Review the CDC Guideline for Disinfection and Sterilization: Focus on environmental surfaces • Review “best” practices for environmental cleaning and disinfection • Review the use of low-level disinfectants and the activity of disinfectants on key hospital pathogens • Discuss options for evaluating environmental cleaning and disinfection • Review “no touch” methods for room decontamination

4. “BEST” PRACTICES • There is little scientific evidence to inform us on cleaning/disinfecting practices and frequency • There is little scientific evidence that disinfecting schedules should emphasize certain “high-risk” or “high-touch” sites

6. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs • Microbial persistence in the environment • In vitro studies and environmental samples • MRSA, VRE, AB, CDI • Frequent environmental contamination • MRSA, VRE, AB, CDI • HCW hand contamination • MRSA, VRE, AB, CDI • Relationship between level of environmental contamination and hand contamination • CDI

7. ENVIRONMENTAL CONTAMINATION LEADS TO HAIS • Person-to-person transmission • Molecular link • MRSA, VRE, AB, CDI • Housing in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease • MRSA, VRE, CDI • Improved surface cleaning/disinfection reduces disease incidence • MRSA, VRE, CDI

8. DISINFECTION AND STERLIZATION • EH Spaulding believed that how an object will be disinfected depended on the object’s intended use • CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile • SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[HLD]) that kills all microorganisms but high numbers of bacterial spores • NONCRITICAL-objects that touch only intact skin require low-level disinfection

9. LECTURE OBJECTIVES • Review the CDC Guideline for Disinfection and Sterilization: Focus on environmental surfaces • Review “best” practices for environmental cleaning and disinfection • Review the use of low-level disinfectants and the activity of disinfectants on key hospital pathogens • Discuss options for evaluating environmental cleaning and disinfection • Review “no touch” methods for room decontamination

10. GUIDELINE FOR DISINFECTIONAND STERILIZATION IN HEALTHCARE FACILITIES, 2008 Rutala WA, Weber DJ., HICPAC Available on CDC web page-www.cdc.gov

11. CATEGORIZATION OF RECOMMENDATIONS

12. DISINFECTION OFNONCRITICAL PATIENT-CARE DEVICES • Process noncritical patient-care devices using a disinfectant and concentration of germicide as recommended in the Guideline (IB) • Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes but multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute (IB) • Ensure that, at a minimum noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (e.g., once daily or weekly) (II) • If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using on a patient, who is on contact precautions before using this equipment on another patient (IB)

13. CLEANING/DISINFECTING NONCRITICAL ITEMS/SURFACES • Some persons have recommended that cleaning frequencies should be based on risk stratification matrix • Probability of contamination • Potential for exposure • Vulnerability of patient • Complex and subjective • Data do not support stratification

14. CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES • Clean housekeeping surfaces (e.g., floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled (II) • Disinfect (or clean) environmental surfaces on a regular basis (e.g., daily, 3x per week) and when surfaces are visibly soiled (II) • Follow manufacturers’ instructions for proper use of disinfecting (or detergent) products – such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal (II) • Clean walls, blinds, and window curtains in patient-care areas when these surfaces are visibly contaminated or soiled (II) • Prepare disinfecting (or detergent) solutions as needed and replace with fresh solution frequently (e.g., replace floor mopping solution every 3 patient rooms, change no less often than at 60-minute intervals) (IB)

15. REVIEW THE “BEST” PRACTICES FOR CLEANING AND DISINFECTING Cleaning and disinfecting is one-step with disinfectant-detergent. No pre-cleaning necessary unless spill or gross contamination. In many cases “best” practices not scientifically determined.

16. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • Wash hands thoroughly and put on gloves • Place wet floor sign at door • Discard disposable items and remove waste and soiled linen • Disinfect (damp wipe) all horizontal, vertical and contact surfaces with a cotton cloth saturated (or microfiber, disposable ) with a disinfectant-detergent solution.

17. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • These surfaces (wipe all surfaces) include, but are not limited to: • Bed rails • Overbed table • Infusion pumps • IV poles/Hanging IV poles • Nurse call box • Monitor cables • Telephone • Countertops

18. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • These surfaces include, but not limited to: • Soap dispenser • Paper towel dispenser • Cabinet fronts including handles • Visitor chair • Door handles inside and outside • Sharps container • TV remote, bed call remote • Bathroom-toilet seat, shower fixtures, flush handle

19. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • Spot clean walls (when visually soiled) with disinfectant-detergent and windows with glass cleaner • Clean and disinfect sink and toilet • Stock soap and paper towel dispensers • Damp mop floor with disinfectant-detergent • Inspect work • Remove gloves and wash hands

20. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • Use EPA-registered disinfectant-detergent (if prepared on-site, document correct concentration) • Cleaned surface should appear visibly wet and should be allowed to air dry at least one minute • Change cotton mop water containing disinfectant every 3 rooms and after every isolation room • Change cotton mop head after isolation room and after BBP spills (change microfiber after each room)

21. DAILY CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • Cleaning should be from the cleanest to dirtiest areas (the bathroom will be cleaned last followed by the floor) • Change cleaning cloths after every room and use at least 3 cloths per room; typically 5-7 cloths • Do not place cleaning cloth back into the disinfectant solution after using it to wipe a surface • Daily cleaning of certain patient equipment is the responsibility of other HCP (RC, nursing). Surfaces should be wiped with a clean cloth soaked in disinfectant

22. TERMINAL CLEANING/DISINFECTING PRACTICESHota et al. J Hosp Infect 2009;71:123 • “Terminal” or discharge cleaning of non-isolation rooms consists of the same procedure above plus disinfection of bed mattresses and inaccessible items • Trash can cleaned weekly and when visible soiled • Do not wash walls, strip and wax floors, or discard wrapped disposable supplies left in drawers

24. CONTAMINATION OF HOSPITAL CURTAINSTrillis et al. 2008. ICHE 29:1074 42% of privacy curtains contaminated with VRE, 22% MRSA and 4% C. difficile

25. Hospital Privacy Curtains(sprayed “grab area” 3x from 6-8” with 1.4% IHP and allowed 2 minute contact; sampled)

26. Decontamination of Curtains with Activated HP (1.4%)Rutala, Gergen, Weber. 2012 * All isolates after disinfection were Bacillus sp

27. TERMINAL CLEANING PRACTICE • Some hospitals change curtains after Contact Precaution patients • At UNC Health Care, privacy curtains are changed routinely every 3 months or when visible soiled • In Contact Precaution rooms, frequently touched surfaces of the curtains are sprayed with approved disinfectant (e.g., improved HP) • Vinyl shower curtains are cleaned when visibly soiled or replaced as needed

28. ISOLATION ROOM CLEANING • ES staff use PPE required by the isolation card • Same cleaning procedures as for non-isolation rooms (except C. difficile, norovirus) • Do not use a dust mop or counter brush • Leave the room only when completed (unless requested to leave by nurse or doctor)

29. Cleaning/Disinfection • ES and nursing need to agree on who is responsible for cleaning what (especially equipment) • ES needs to know • Which disinfectant/detergent to use • What concentration would be used (and verified) • What contact times are recommended (bactericidal) • How often to change cleaning cloths/mop heads • How important their job is to infection prevention

30. LECTURE OBJECTIVES • Review the CDC Guideline for Disinfection and Sterilization: Focus on environmental surfaces • Review “best” practices for environmental cleaning and disinfection • Review the use of low-level disinfectants and the activity of disinfectants on key hospital pathogens • Discuss options for evaluating environmental cleaning and disinfection • Review “no touch” methods for room decontamination

31. DISINFECTING NONCRITICAL PATIENT EQUIPMENT AND ENVIRONMENTAL SURFACES Classification: Noncritical objects will not come in contact with mucous membranes or skin that is not intact. Object: Can be expected to be contaminated with some microorganisms. Level germicidal action: Kill vegetative bacteria, fungi and lipid viruses. Examples: Bedpans; crutches; bed rails; EKG leads; bedside tables; walls, floors and furniture. Method: Low-level disinfection

32. PROPERTIES OF AN IDEAL DISINFECTANT Rutala, 1995. Modified from Molinari 1987. • Broad spectrum-wide antimicrobial spectrum • Fast acting-should produce a rapid kill • Not affected by environmental factors-active in the presence of organic matter • Nontoxic-not irritating to user • Surface compatibility-should not corrode instruments and metallic surfaces • Residual effect on treated surface-leave an antimicrobial film on treated surface • Easy to use • Odorless-pleasant or no odor • Economical-cost should not be prohibitively high • Soluble (in water) and stable (in concentrate and use dilution) • Cleaner (good cleaning properties) and nonflammable

33. LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol 70-90% Chlorine 100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

34. IMPROVED HYDROGEN PEROXIDE SURFACE DISINFECTANT • Advantages • 30 sec -1 min bactericidal and virucidal claim (fastest non-bleach contact time) • 5 min mycobactericidal claim • Safe for workers (lowest EPA toxicity category, IV) • Benign for the environment; noncorrosive; surface compatible • One step cleaner-disinfectant • No harsh chemical odor • EPA registered (0.5% RTU, 1.4% RTU, wet wipe) • Disadvantages • More expensive than QUAT

35. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. In press Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested

36. LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol 70-90% Chlorine 100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

37. Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants Prions Spores (C. difficile) Mycobacteria Non-Enveloped Viruses (norovirus) Fungi Bacteria (MRSA, VRE,Acinetobacter) Enveloped Viruses Most Resistant Most Susceptible

38. SHOULD WE CONCENTRATE ON “HIGH TOUCH” OR “HIGH RISK” OBJECTS No, not only “high risk” (all surfaces). “High touch” objects only recently defined and “high risk” objects not scientifically defined.

39. DEFINING HIGH TOUCH SURFACES ICU Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. ICHE 2010;31:850-853

40. DEFINING HIGH TOUCH SURFACES Non-ICU Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. ICHE 2010;31:850-853

42. Microbiologic Assessment of High, Medium and Low Touch Surfaces. Huslage, Rutala, Gergen, Weber. ICHE. In press No correlation between touch frequency and microbial contamination

44. Thoroughness of Environmental CleaningCarling et al. ECCMID, Milan, Italy, May 2011 >110,000 Objects Mean = 32%

45. Mean proportion of surfaces disinfected at terminal cleaning is 32% Terminal cleaning methods ineffective (products effective practices deficient [surfaces not wiped]) in eliminating epidemiologically important pathogens

46. Effective Surface Decontamination Practice and Product

47. EFFECTIVENESS OF DISINFECTANTS AGAINST MRSA AND VRE Rutala WA, et al. Infect Control Hosp Epidemiol 2000;21:33-38.

48. Not Product: Is It Practice?

49. SURFACE DISINFECTIONEffectiveness of Different Methods Rutala, Gergen, Weber. Unpublished data.

50. Practice* NOT Product *surfaces not wiped